DEPOSITORY INFORMATIONName of Bank or DepositoryMailing AddressCityStateZip Code (Area Code) Day TelephoneAccount NameAccount Number*Leave this field blank if your telephone number is unlisted. Pursuant to N.J.S.A. 47:1A-1.1, an unlisted telephone number is not a public record and must not be provided on this form.New Jersey Election Law Enforcement CommissionPage 1 of 2sForm D-1 Revised Mar. 2018

CANDIDATE CERTIFICATION: I certify that the statements on this document are true. I further certify that I have not, and will not during the existence of the candidate committee, establish, authorize the establishment of, maintain, or participate directly or indirectly in the management or control of any political committee or continuing political committee. I am aware that if any of the statements are willfully false, I may be subject to punishment.Registration NumberPINDateCandidateCHAIRPERSON/TREASURER CERTIFICATION: I certify that the statements on this document are true. I am aware that if any of the statements are willfully false, I may be subject to punishment.Registration NumberPINDateChairpersonRegistration NumberPINDateTreasurerTreasurers for Gubernatorial and Legislative candidates are required to receive training with the NJ ELEC. If you have completed the training enter your Treasurer Training ID#*Leave this field blank if your telephone number is unlisted. Pursuant to N.J.S.A. 47:1A-1.1, an unlisted telephone number is not a public record and must not be provided on this form.New Jersey Election Law Enforcement CommissionPage 2 of 2sForm D-1 Revised Mar. 2018